Work of a nurse in a health centre treatment room

In six months there were 1,704 attendances at the treatment room of a small health centre. The attendance rate for the population registered with the health centre doctors was 448 per 1,000 patients per year. Females between 15 and 44 years and males under 15 had the highest attendance rates. There were 256 casual attenders, 58 (23%) of whom were referred to a doctor or hospital for further advice or treatment.It is suggested that in a health centre treatment room about six hours of nursing time a week for every 1,000 patients is required, and that a case can be made out for some of the routine work of casualty departments being done in health centres.     

Trauma services requirements in a district general hospital serving a rural area.

OBJECTIVE--To assess the demands made on a regional trauma centre by a district trauma unit. DESIGN--Two part study. (1) Prospective analysis of one month''s workload. (2) Retrospective analysis of one year''s workload by using a computer based records system. Comparison of two sets of results. SETTING--Accident unit in Gwynedd Hospital, Bangor. PATIENTS--(1) All patients who attended the accident unit in August 1988. (2) All patients who attended the accident unit in the calendar year April 1988-April 1989. MAIN OUTCOME MEASURE--Workload of a district trauma unit. RESULTS--In August 1988 there were 2325 attendances; 2302 of these were analysed. In all, 1904 attendances were for trauma; 213 patients were admitted to the trauma ward and 103 required an operation that entailed incision. Patients who attended the unit had a mean (range) injury severity score of 2-13 (0-25). Only two patients had injuries that a district general hospital would not be expected to cope with (injury severity score greater than 20). In the year April 1988-April 1989, 21,007 patients attended the unit. In all, 17,958 attendances were for orthopaedic injuries or injuries caused by an accident; 1966 patients were admitted to the unit. CONCLUSIONS--Most trauma is musculoskeletal and relatively minor according to the injury severity score. All but a few injuries can be managed in district general hospitals. In their recent report the Royal College of Surgeons has overestimated the requirements that a British district general hospital would have of a regional trauma centre.     

Effect of NHS walk-in centre on local primary healthcare services: before and after observational study

ObjectiveTo assess the effect of an NHS walk-in centre on local primary and emergency healthcare services.DesignBefore and after observational study.SettingLoughborough, which had an NHS walk-in centre, and Market Harborough, the control town.Participants12 general practices.ResultsThe change between the before and after study periods was not significantly different in the two towns for daily rate of emergency general practice consultations (mean difference −0.02/1000 population, 95% confidence interval −0.75 to 0.71), the time to the sixth bookable routine appointment (−0.24 half-days, −1.85 to 1.37), and daily rate of attendances at out of hours services (0.07/1000 population, −0.06 to 0.19). However, attendance at the local minor injuries unit was significantly higher in Loughborough than Market Harborough (rate ratio 1.22, 1.12 to 1.33). Non-ambulance attendances at accident and emergency departments fell less in Loughborough than Market Harborough (rate ratio 1.17, 1.03 to 1.33).ConclusionsThe NHS walk-in centre did not greatly affect the workload of local general practitioners. However, the workload of the local minor injuries unit increased significantly, probably because it was in the same building as the walk-in centre.

What is already known on this topic

Walk-in centres are well established in North America but differ from NHS centres as they are run by doctors not nurses

What this study adds

Introduction of an NHS walk-in centre did not affect the workload of local general practitionersAttendance increased at the minor injuries unit, which was in the same buildingNon-ambulance attendances at accident and emergency departments decreased but not by as much as in the control area     

Contribution of a general practitioner hospital: a further study.

OBJECTIVE--To audit the workload of a general practitioner hospital and to compare the results with an earlier study. DESIGN--Prospective recording of discharges from the general practitioner hospital plus outpatient and casualty attendances and of all outpatient referrals and discharges from other hospitals of patients from Brecon Medical Group Practice during one year (1 June 1986-31 May 1987). SETTING--A large rural general group practice which staffs a general practitioner hospital in Brecon, mid-Wales. PATIENTS--20,000 Patients living in the Brecon area. RESULTS--1540 Patients were discharged from the general practitioner hospital during the study period. The hospital accounted for 78% (1242 out of 1594) of all hospital admissions of patients of the practice. There were 5835 new attendances at the casualty department and 1896 new outpatient attendances at consultant clinics at the hospital. Of all new outpatient attendances by patients of the practice, 71% (1358 out of 1896) were at clinics held at the general practitioner hospital. Since the previous study in 1971 discharges from the hospital have increased 37% (from 1125 to 1540) and new attendances at consultant clinics 30% (from 1450 to 1896). The average cost per inpatient day is lower at this hospital than at the local district general hospital (pounds 71.07 v pounds 88.06 respectively). CONCLUSIONS--The general practitioner hospital deals with a considerably larger proportion of admissions and outpatient attendances of patients in the practice than in 1971 and eases the burden on the local district general hospital at a reasonable cost. IMPLICATIONS--General practitioner hospitals should have a future role in the NHS.     

Self referral to an accident and emergency department for another opinion.

OBJECTIVE--To determine whether patients referring themselves to an accident and emergency department for another opinion after consulting their general practitioner present with serious illness, show any risk factors for being admitted, or are more likely to be patients of particular practitioners. DESIGN--Six month prospective survey. SETTING--District general hospital''s accident and emergency department, receiving 42,000 new patients a year. PATIENTS--180 Patients identified as attending for another opinion having already consulted a general practitioner. INTERVENTIONS--Classified as admission, referral to specialist clinic, follow up in accident and emergency department, or referral back to general practitioner. END POINT--Admission, with an analysis of admitted patients. MEASUREMENTS AND MAIN RESULTS--General outcome, diagnostic category, age, time of attendance, time since seen by general practitioner, and name of general practitioner were recorded. Forty seven patients were admitted, 99 were discharged back to the general practitioner (62 without a letter), and two died. Patients were most likely to be admitted if they attended within 24 hours after seeing a general practitioner, were aged under 5, or presented with respiratory or gastrointestinal complaints. Some general practitioners were overrepresented. CONCLUSIONS--Important disorders present in this way, and therefore these patients should be seen by a doctor. Information about these attendances could be useful to general practitioners in reviewing their performance.     

The extent of the two tier service for fundholders.

OBJECTIVE--To examine possible differential changes in outpatient referrals to orthopaedic clinics, attendances, and waiting times between fundholding and non-fundholding general practitioners. DESIGN--Observational controlled study of referrals by general practitioners to orthopaedic outpatients between April 1991 and March 1995. SETTING--District health authority in south-west England. SUBJECTS--10 fundholding practices with 108,300 registered patients; 22 control practices with 159,900 registered patients. MAIN OUTCOME MEASURES--Changes in age standardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status; changes in outpatient waiting times. RESULTS--In the year before achieving fundholding status both groups were referring more patients than were being seen. Two years later, referral and attendance ratios had increased by 13% and 36% respectively for fundholders and 32% and 59% for controls, and both groups were referring fewer patients than were being seen. Attendances represented 112% of referrals for fundholders and 104% for controls. In 1991-2, a similar proportion of patients in the two groups was seen within three months of referral. The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993-4, as did a third hospital without such clinics by 1994-5. CONCLUSIONS--Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals. Their patients were likely to be seen more quickly, particularly if the hospital provided special clinics exclusively for fundholders. Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients.     

Evaluation of the efficacy and acceptability to patients of a physiotherapist working in a health centre.

The records of the first 805 patients who had been referred by general practitioners at this health centre to the attached physiotherapist were examined in November 1985, three years after the physiotherapy department was opened. Seventy per cent (549) of the patients had been treated within one week, treatment having started on the same day for 8.5% (67) of the patients. This compares with a mean of six weeks for direct access to a district general hospital that is eight miles away and between six and 13 months for the three nearest orthopaedic consultants who are 13 miles away. The most common conditions treated were knee injuries (16.5%), followed by cervical (15.5%) and shoulder (13.8%) injuries. Surprisingly, only 9% were back injuries. The non-attendance rate was 2.2% and only 7% of patients failed to complete treatment. Nearly all the patients were able to attend the clinic, only 4% requiring home treatment. By March 1986, 90 treatments a week were being carried out at a cost of 6.11 pounds per patient. Compared with official hospital figures, this represents a savings of 21,500 pounds a year for a practice of 12,000 patients.     

Improving the care of patients with major trauma in the accident and emergency department.

OBJECTIVE--To determine whether improvement in the care of victims of major trauma could be made by using the revised trauma score as a triage tool to help junior accident and emergency doctors rapidly identify seriously injured patients and thereby call a senior accident and emergency specialist to supervise their resuscitation. DESIGN--Comparison of results of audit of management of all seriously injured patients before and after these measures were introduced. SETTING--Accident and emergency department in an urban hospital. PATIENTS--All seriously injured patients (injury severity score greater than 15) admitted to the department six months before and one year after introduction of the measures. RESULTS--Management errors were reduced from 58% (21/36) to 30% (16/54) (p less than 0.01). Correct treatment rather than improvement in diagnosis or investigation accounted for almost all the improvement. CONCLUSIONS--The management of seriously injured patients in the accident and emergency department can be improved by introducing two simple measures: using the revised trauma score as a triage tool to help junior doctors in the accident and emergency department rapidly identify seriously injured patients, and calling a senior accident and emergency specialist to supervise the resuscitation of all seriously injured patients. IMPLICATIONS--Care of patients in accident and emergency departments can be improved considerably at no additional expense by introducing two simple measures.     

Characteristics of children presenting with chest pain to a pediatric emergency department.

Chest pain among children is a common complaint in primary care practice. However, the demographic features and treatment of such patients are controversial. We distributed a questionnaire to 336 consecutive patients with a complaint of chest pain seen during 1 year at an urban pediatric emergency department. Such visits represented 0.6% of all emergency encounters; the male:female ratio was 1.0. Physical examination was done in 325 patients. Chest-wall pain was the most common diagnosis (in 28% of cases). Other causes included pulmonary (in 19%), minor traumatic (in 15%), idiopathic (in 12%) and psychogenic (in 5%); miscellaneous causes (in 21%) most often indicated pain referred from the upper respiratory tract and the abdomen. The most common physical finding was chest tenderness (in 41% of cases). Investigations included chest radiography (in 50% of cases), electrocardiography (in 18%) and determination of the hemoglobin concentration and of the leukocyte count (in 13%); the results were rarely positive. Only eight patients (2%) required admission to hospital, and there were no cases of myocardial ischemia. The findings suggest that health care costs may be reduced by more judicious use of investigations. We conclude that chest pain is an uncommon and usually benign complaint in the pediatric emergency department. Most causes are evident on careful physical examination.     

New programme of antenatal care in general practice.

The conclusions from recent analyses of the clinical worth of routine antenatal attendances have been used in the setting of a modern primary health care team. As a result the number of times a low risk nulliparous woman is seen by her general practitioner has been reduced from 15 to eight and a low risk multiparous woman from 15 to six. The number of consultations with a midwife has also been considerably reduced. The time saved is used in longer, more structured consultations and for more intensive care of high risk, usually socially deprived, women. Despite these reductions in consultations organised, well recorded care of this type renders antenatal attendances at a hospital virtually unnecessary for low risk women.     

Excessive use of psychiatric services by suicidal patients.

The use of psychiatric services by patients with a suicidal history was examined to see if they placed a greater long-term burden on these services than other types of patient. Suicidal patients spent significantly more days in hospital and made more outpatient attendances; suicide attemptors in particular not only needed more emergency consultations but also spent more days in hospital. A more economical yet more effective treatment policy for the suicidal patient is needed.     

Home Accidents to Children under 15 Years: Survey of 910 Cases

Out of 910 accidents sustained by children under 15 seen at the casualty department of a local hospital 678 (74·5%) were to children under 5 years of age. Boys were more prone to accidents than girls, and in preschool children the highest incidence of accidents was among the 2-to 3-year-olds of both sexes. Social class had no significant bearing on the accident rate. The fact that the average size of families with children under 5 was higher among families living in council houses than among those living in private houses appeared to have some bearing on the higher incidence of accidents among children under 5 living in council houses. There appeared to be no peak month when accidents were more frequent and the incidence of accidents was not significantly high on any particular weekday. In 95% of the cases one or both parents were in charge of the child at the time of the accident.Cuts were the most common types of accident followed by falls and poisoning. Among other accidents crushed fingers were as frequent as burns. A total of 62 patients (6·8% of all cases) were admitted as inpatients. Of the actual causes of the cuts and falls playing, fighting, and misbehaving were the most common followed by falling from beds, chairs, etc. While there is a need for health education programmes to draw attention to the specific dangers evidenced there clearly will always be home accidents.     

Impact of NHS walk-in centres on the workload of other local healthcare providers: time series analysis

ObjectivesTo assess the impact of NHS walk-in centres on the workload of local accident and emergency departments, general practices, and out of hours services.DesignTime series analysis in walk-in centre sites with no-treatment control series in matched sites.SettingWalk-in centres and matched control towns without walk-in centres in England.Participants20 accident and emergency departments, 40 general practices, and 14 out of hours services within 3 km of a walk-in centre or the centre of a control town.ResultsA reduction in consultations at emergency departments (–175 (95% confidence interval –387 to 36) consultations per department per month) and general practices (–19.8 (−53.3 to 13.8) consultations per 1000 patients per month) close to walk-in centres became apparent, although these reductions were not statistically significant. Walk-in centres did not have any impact on consultations on out of hours services.ConclusionIt will be necessary to assess the impact of walk-in centres in a larger number of sites and over a prolonged period, to determine whether they reduce the demand on other local NHS providers.

What is already known on this topic

One of the objectives for NHS walk-in centres was to reduce demand on other NHS services, particularly general practitioners'' services and accident and emergency departmentsStudies of walk-in centres in North America have indicated that such centres do not reduce demand on other healthcare servicesStudies of minor injuries units in the United Kingdom (which have some similarities with walk-in centres) indicate that these units substitute mainly for consultations in accident and emergency departments

What this study adds

The data imply that walk-in centres may moderate the increasing demand on general practice and reduce the number of consultations in accident and emergency departmentsThe high level of background variability in consultation rates means that any impact of a walk-in centre is not statistically significantTo draw robust conclusions about the impact of walk-in centres on other health providers will require study of a large number of sites over an extended period of time     

Home treatment for acute psychiatric illness.

OBJECTIVE--To determine the factors influencing the successful outcome of community treatment for severe acute psychiatric illnesses that are traditionally treated in hospital. DESIGN--All patients from a single electoral ward who were either admitted to hospital or treated at home over a two year period (1 October 1987 to 30 September 1989) were included in the study and their case notes audited. The second year of the study is reported. SETTING--Electoral ward of Sparkbrook, Birmingham. SUBJECTS--99 Patients aged 16-65 with severe acute psychiatric illness. RESULTS--65 Patients were managed by home treatment alone; 34 required admission to hospital. The location of treatment was significantly (all p less than 0.05) influenced by social characteristics of the patients (marital state, age (in men), ethnicity, and living alone) and by characteristics of the referral (occurring out of hours; assessment taking place at hospital or police station). DSM-III-R diagnosis was more weakly associated with outcome. Violence during the episode was significantly related to admission, although deliberate self harm was not. CONCLUSIONS--Home treatment is feasible for most patients with acute psychiatric illness. A 24 hour on call assessment service increases the likelihood of success because admission is determined more strongly by social characteristics of the patient and the referral than by illness factors. Admission will still be required for some patients. A locally based mental health resource centre, a 24 hour on call service, an open referral system, and an active follow up policy increase the effectiveness of a home treatment service.     

Bristol Floods 1968. Controlled Survey of Effects on Health of Local Community Disaster

An investigation into the health of people in Bristol flooded in July 1968 was made by means of a controlled survey and a study of mortality rates. There was a 50% increase in the number of deaths among those whose homes had been flooded, with a conspicuous rise in deaths from cancer.Surgery attendances rose by 53%, referrals to hospital and hospital admissions more than doubled. In all respects the men appeared less well able to cope with the experience of disaster than the women.     

Epidemiology of Mental Health Attendances at Emergency Departments: Systematic Review and Meta-Analysis

BackgroundThe characteristics of Emergency Department (ED) attendances due to mental or behavioural health disorders need to be described to enable appropriate development of services. We aimed to describe the epidemiology of mental health-related ED attendances within health care systems free at the point of access, including clinical reason for presentation, previous service use, and patient sociodemographic characteristics.MethodSystematic review and meta-analysis of observational studies describing ED attendances by patients with common mental health conditions.Findings18 studies from seven countries met eligibility criteria. Patients attending due to mental or behavioural health disorders accounted for 4% of ED attendances; a third were due to self-harm or suicidal ideation. 58.1% of attendees had a history of psychiatric illness and up to 58% were admitted. The majority of studies were single site and of low quality so results must be interpreted cautiously.ConclusionsPrevalence studies of mental health-related ED attendances are required to enable the development of services to meet specific needs.     

The Organization of Hospital Services for Casualties due to the Bombing of Cities,Based on Experience Gained in Barcelona-with Special Reference to the Classification of Casualties: (Section of Orthopædics)

(1) Difference between modern "total population" war and old-fashioned war. Difference between bombing of (a) military objectives and (b) civilian population.(a) The heavy bomb, e.g. 750 lb., with large fragments, upward throw, great destruction of buildings.(b) The light bomb with finger nail fragments, horizontal throw, great velocity.There is in addition the incendiary bomb, little used in Barcelona because the buildings are built of stone and concrete.(2) Aerial bombing of a town produces injuries needing more immediate hospitalization than most front-line wounds. At the same time it is possible in a town to organize rapid collection of patients and their immediate transfer to hospital.(3) Experience shows that it is most desirable to make this transfer of patients to hospital a primary consideration. On arrival they are "sorted" and minor injuries are given First Aid treatment and sent home, others are fully examined, classified, and dispatched to the theatres on a priority list, to nearby wards for resuscitation, to wards for rest, or sent on to plaster rooms for splintage, or to a neurosurgical centre.(4) First-aid posts in a town should be in hospitals and treat superficial injuries, &c., after primary sorting in the hospital reception room.(5) First-aid posts in outlying areas should carry out the same function for the same type of cases; all the more seriously wounded, including those with tiny penetrating wounds, should be dispatched without first aid treatment direct to hospital.(6) Hospital arrangements, for circulation of ambulances, for sorting, undressing of patients, docketing of valuables, &c.(7) Classification must be carried out by surgeons of experience and judgment. They must regard not only a standard priority list but the particular clinical picture and prognosis in each case.(8) The surgeon will furthermore draft the cases with regard to the special abilities of the surgical units available, e.g. chest, abdomen, or limbs.(9) Review of wounds in limbs, chest, abdomen, and head, caused by fragments from heavy bombs or by splinters from small light bombs.(10) Injuries from falling masonry.(11) Standard classification by urgency of operation.(12) Classification re possible early evacuation.     

Profile of an Accident Flying Squad

An analysis of 184 accident flying squad calls and of 280 patients injured in road accidents and treated by a flying squad based on an accident department inclusive from 1967 to 1971 has shown that such a service can provide an efficient system without disrupting the routine work of the hospital.     

某军队大型综合医院全麻择期手术流程的干预研究

手术室是为病人提供手术及抢救的场所,是医院的重要核心技术部门。手术室的正常、高效、科学运行关系到了所有外科科室及与手术相关科室的整体效率。因此,针对目前手术科室术前等待时间过长,手术台次安排低效的情况,通过对某军队大型三级甲等医院24 间手术室的全麻手术运行情况进行跟踪调查,运用专家咨询、调查问卷、头脑风暴等方法对手术运转流程进行分析并采取干预措施,破除制约手术科室的瓶颈,提高手术科室的效率。